Sexual scripting of heterosexual penile-anal intercourse ...

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Culture, Health & SexualityAn International Journal for Research, Intervention and Care

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Sexual scripting of heterosexual penile-analintercourse amongst participants in an HIVprevention trial in South Africa, Uganda andZimbabwe

Zoe Duby, Miriam Hartmann, Elizabeth T. Montgomery, Christopher J. Colvin,Barbara Mensch & Ariane van der Straten

To cite this article: Zoe Duby, Miriam Hartmann, Elizabeth T. Montgomery, Christopher J.Colvin, Barbara Mensch & Ariane van der Straten (2016) Sexual scripting of heterosexualpenile-anal intercourse amongst participants in an HIV prevention trial in South Africa, Ugandaand Zimbabwe, Culture, Health & Sexuality, 18:1, 30-44, DOI: 10.1080/13691058.2015.1064165

To link to this article: http://dx.doi.org/10.1080/13691058.2015.1064165

Published online: 30 Jul 2015.

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Culture, HealtH & Sexuality, 2016VOl. 18, NO. 1, 30–44http://dx.doi.org/10.1080/13691058.2015.1064165

Sexual scripting of heterosexual penile-anal intercourse amongst participants in an HIV prevention trial in South Africa, Uganda and Zimbabwe

Zoe Dubya,b  , Miriam Hartmannc, Elizabeth T. Montgomeryc, Christopher J. Colvinb, Barbara Menschd and Ariane van der Stratenc,e

aDesmond tutu HiV Centre, Department of Medicine, university of Cape town, Cape town, South africa; bSchool of Public Health & Family Medicine, university of Cape town, Cape town, South africa; cWomen’s Global Health imperative, rti international, San Francisco, uSa; dPopulation Council, New york, uSa; euniversity of California San Francisco, San Francisco, uSa

IntroductionCondomless penile-anal intercourse is a high-risk sexual activity for HIV transmission; moreover engaging in heterosexual penile-anal intercourse has also been shown to be associated with other practices that increase HIV risk, such as condomless sex, alcohol and substance use, trading sex and having multiple concurrent sexual partners (Kalichman et al. 2009). Limited evidence suggests that women in sub-Saharan Africa substitute penile-anal

ABSTRACTSexual risk-taking is influenced by individual, interpersonal and social factors. This paper presents findings from a qualitative follow-up study to a clinical trial evaluating biomedical HIV prevention products among African women, explored participants’ perceptions and experiences of heterosexual penile-anal intercourse, as well as the gendered power dynamics and relationship contexts in which this sexual behaviour occurs. In-depth interviews were conducted with 88 women from South Africa, Uganda and Zimbabwe. Findings reveal that despite its social stigmatisation, women engage in penile-anal intercourse for reasons including male pleasure, relationship security, hiding infidelity, menstruation, vaginal infections, money and beliefs that it will prevent HIV transmission. In addition, participants described experiences of non-consensual penile-anal intercourse. We used sexual scripting theory as an analytical framework with which to describe the sociocultural and relationship contexts and gendered power dynamics in which these practices occur. These data on the distinct individual, dyadic and social contexts of heterosexual penile-anal intercourse, and the specific factors that may contribute to women’s HIV risk, make a unique contribution to our understanding of heterosexual behaviour in these sub-Saharan countries, thereby helping to inform both current and future HIV prevention efforts for women in the region.

© 2015 taylor & Francis

KEYWORDSanal intercourse; heterosexual; sub-Saharan africa; sexual script; gender; HiV

ARTICLE HISTORYreceived 4 February 2015 accepted 16 June 2015

CONTACT Zoe Duby [email protected]

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intercourse for vaginal sex for an array of reasons, including as a means of contraception, during menstruation, to ensure relationship stability and because they perceive it as a way to avoid contracting sexually transmitted infections (STIs) and HIV (Duby and Colvin 2014).

Heterosexual decision-making is limited by gendered power inequities; unequal gendered power distribution and male-to-female HIV transmission are correlated (rosenthal and Levy 2010). Although there is variation between cultures, traditional gender roles generally por-tray men as the dominant, controlling initiators in heterosexual relationships. Gender norms encourage women to be submissive, prioritising the maintenance of intimate partnerships over their own needs; thus women often engage in sexual practices they are uncomfortable with, or engage in sex when they do not want to (Bowleg, Lucas, and Tschann 2004; Maynard et al. 2009; O’Sullivan, Udell, and Patel 2006; roye, Tolman, and Snowden 2013).

As an analytic framework with which to interpret study participants’ descriptions of the social and dyadic contexts within which penile-anal intercourse occurs, we used the sexual scripting theory developed by Gagnon and Simon (1973). This theory provides a contextu-ally grounded approach to understanding sexual behaviour by focusing on sociocultural directives that guide the conduct of sexual relationships and frame the organisation and interpretation of sexual interactions; these directives are in accordance with socially pre-scribed roles based on gender, age, socioeconomic class and ethnicity (Bowleg, Lucas, and Tschann 2004; Gagnon 1990; Wiederman 2005). Sexual communication, partner selection, gendered power negotiations, decision making, risk taking and the ability to shape one’s own and another’s actions are central to sexual interaction (Dworkin, Beckford, and Ehrhardt 2007). Because of this, scripting theory is useful in analysing relationship contexts and gen-dered power dynamics that influence an individual’s ability to engage in HIV risk reduction practices (McLellan-Lemal et al. 2013).

Gendered sexual scripts inform agency or power in the dyadic context, determining the capacity to dominate decision making processes that affect both partners, and the ability to engage in behaviours against a sexual partner’s wishes or to control the behaviour of a partner. Traditional heterosexual gender norms accept male aggression and dominance over women, condoning violence in sexual and intimate partnerships (Flood and Pease 2009). Women’s lack of sexual agency and control over their own bodies facilitates their exposure to HIV (Dworkin, Beckford, and Ehrhardt 2007; Kaufman et al. 2008; Pulerwitz, Gortmaker, and DeJong 2000; rosenthal and Levy 2010).

The culturally scripted expectation that women should defer to a male partner’s sexual needs gives primacy to male pleasure at the expense of safer-sex measures. Because of this, women tend to leave condom initiation and use to men and also accept that men can have multiple sexual partners (Dworkin, Beckford, and Ehrhardt 2007; Norris, Masters, and Zawacki 2004). research in sub-Saharan Africa has shown that women with the least power and those who fear violence or negative relationship outcomes are at the highest risk for HIV infection. They are also the least likely to be able to effectively negotiate condom use and other safer-sex practices (Kaufman et al. 2008).

Evidence is lacking with regards to gendered power and relationship dynamics as they relate to heterosexual penile-anal intercourse practice in sub-Saharan Africa; sexual decision making and risk taking for heterosexual penile-anal intercourse and penile-vaginal inter-course are likely to differ (roye, Tolman, and Snowden 2013). In order to understand the potential contribution that heterosexual penile-anal intercourse makes to HIV transmission to women, it is critical to identify motivations for engaging in it, the behavioural and social

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contexts, and the dynamics of gendered power and sexual scripting surrounding its practice (Tanner et al. 2009).

MethodsThis qualitative study was completed after the completion of a multisite HIV clinical preven-tion trial conducted between 2009 and 2012, to test pre-exposure prophylaxis HIV prevention products, a daily vaginal gel and two daily oral tablets (Marrazzo et al. 2015). This study took a broad approach to understand experiences, motivations and the role of context in the clinical trial participants’ sexual behaviour during the trial. In-depth interviews were used to investigate perceptions and practice of penile-anal intercourse amongst participants. Ethical approval for the current study was obtained from ethics committees at each of the study sites in Zimbabwe, Uganda and South Africa as well as rTI International, USA, and the University of Cape Town, South Africa.

Participants for the current study were pre-selected for participation to ensure that at least 10% had reported engaging in penile-anal intercourse whilst enrolled in the clinical trial, and approximately 10% had acquired HIV. All participants, regardless of whether or not they had previously self-reported penile-anal intercourse, were asked about their perceptions and practice with respect to the behaviour. Interviews were conducted in participants’ language of preference (Zulu, Luganda, Shona or English) and followed a semi-structured format.

Audio recordings of interviews were transcribed verbatim into their original language, reviewed by the interviewer, translated into English and then reviewed again. A codebook was iteratively developed reflecting the study’s key objectives and topics that emerged through reading the data. Qualitative data were coded and thematically analysed using the NVivo 10 software package (QSr International) by a team of four analysts; ≥ 80% inter-coder reliability was established and verified on ~10% of the transcripts throughout the coding process.

ResultsTable 1 presents demographic characteristics of the study sample (n = 88), by country. Although almost all participants (95%) reported having a current primary sex partner, mar-ital status varied by site, ranging from most (85%) married in Zimbabwe to none in South Africa. A similar pattern was reported for cohabitation. Whereas women in Zimbabwe and South Africa reported an average of 2–3 lifetime sexual partners and no other partners in the past three months, some Ugandan participants reported engaging in transactional sex; the sample from this site reported an average of 31 lifetime partners, and 16 in the past three months.

The data presented below relate to perceptions and attitudes towards penile-anal inter-course, motivations for penile-anal intercourse, gendered power dynamics and relationship contexts in which heterosexual penile-anal intercourse takes place, including forced penile-anal intercourse. Direct quotations (translated) from participants are presented below, fol-lowed by brackets including a pseudonym and details of the participant’s nationality and age.

Perceptions of and attitudes towards penile-anal intercourse

Anal sex taboosThe introductory statement to the anal sex section of the interviews, that approximately 900 women in our earlier study had reported having had penile-anal intercourse in the

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past three months, elicited a range of reactions from participants including shock, disgust, embarrassment, amusement and disbelief:

Nobody has anal sex …. There is nobody who does that, there isn’t … this [vagina] is the part where you have sex. Why would you have sex in the anus …? (Zoliswa, South African, age 39)

The general opinion expressed by participants was that due to social stigma and shame, if a woman did engage in penile-anal intercourse, she would keep it secret, as disclosing anal intercourse would result in other people viewing her as a ‘loose’ woman with no morals:

[Anal sex] is done in secrecy in Uganda. It is not something you let other people know about. Whoever does it, does so at their own peril … it is done in hiding … because it is a shameful act. (Margaret, Ugandan, age 36)

Cultural prohibition and silencing of anal sexuality was also cited. One Zimbabwean par-ticipant described the tradition in which anatete [aunts] instruct their nieces in the ways of sex, explaining that anal intercourse was not included in these lessons:

They [aunts] never say your husband will make love to you from that side [the anus] [laughing] … they will tell you that this [your vagina] is your husband’s part and it must be thoroughly cleaned. They will never say you can use the other part [anus] … (Chipo, Zimbabwean, age 30)

Table 1. Sample demographic characteristics.

Note: 1Values of ‘99’ mean ‘99 or more sexual partners’.

Demographic characteristics All countries South Africa Uganda Zimbabwe

n = 88 n = 40 n = 22 n = 26age (median, mean, range) 27, 28.6, 20–40 25, 26.7, 20–40 31, 31, 20–39 30, 29.5, 22–40Completed secondary school or more: n (%)

37 (42) 20 (50) 3 (14) 14 (54)

religion: n (%) Christian 79 (90) 37 (93) 16 (73) 26 (100) Muslim 6 (7) – 6 (27) – Other/none 3 (3) 3 (8) – – regularly attends religious

services (1+/week)78 (89) 33 (83) 19 (86) 26 (100)

relationship/sexual partners: n (%) Currently married 35 (40) - 13 (59) 22 (85) Has current primary sex partner

or married84 (95) 38 (95) 22 (100) 24 (92)

Number of sexual partners in lifetime (median, mean, range)1

2, 9.9, 1–99 2, 3.3, 1–15 5, 31.2, 2–99 1, 2.1, 1–10

among those with current primary sex partner or married: n (%) Currently living with primary

sex partner37 (44) 5 (13) 10 (45) 22 (92)

Partner provides financial support

74 (88) 32 (84) 20 (91) 22 (92)

Vaginal sex in past 3 months with primary sex partner

83 (98) 37 (97) 22 (100) 24 (100)

Number of other partners in last 3 months (median, mean, range)1

0, 4.1, 0–99 0, 0.1, 0–1 1, 16, 0–99 0, 0, 0–1

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Religious proscriptionreligion influenced perceptions and attitudes towards penile-anal intercourse. As shown in Table 1, 97% of participants categorised themselves as either Christian or Muslim. Women, most notably Ugandans, cited their religious beliefs classifying penile-anal intercourse as an unacceptable, shameful and sinful act because the anus was ‘created’ for defaecation, not sex:

When you are a normal person you should reason and know that such sex [anal sex] is not good. you have sex as God said … directly in the vagina … God … created us that we should have sex through the vagina, so what would be the reason why you should have sex from behind [in the anus]? … the anus was also created by God … for poo [passing out faeces]. (ruth, Ugandan, age 34)

Participants who expressed religious views described people who engaged in anal sex as sinners using the body for purposes against God’s design:

When I look at those women [who have anal sex] they are no longer human … There is a way God made [us] … He gave a vagina and the anus and there are different ways in which He created them … God put a vagina and an anus and each has its own purpose. The anus passes faeces, and in the vagina is where everything to do with sex is done. (Mutesi, Ugandan, age 39)

Some participants proclaimed that anal sex was ‘inhuman’, only practised by perverse, ‘messed up’, ‘insane’ or mentally ill people:

It is horrible … [anal sex] is total madness. Those people are sick. … It is not normal. (Nesta, Zimbabwean, age 33)

One participant explained that because the anus wasn’t specifically ‘created’ for sex in the same way the vagina was, anal sex is unsafe and damaging:

God created the front for [sex] … in the vagina, God created some special friction which is smooth during sex. If you use the anus, it has to be forceful making it easier to get diseases as opposed to the vagina … God created it [the vagina] as an entrance and the anus as an exit. (Eunice, Ugandan, age 33)

Othering of penile-anal intercourse behaviourMany participants believed that penile-anal intercourse was introduced into their countries by White people, or by those watching Western pornography, and that the only women who engage in penile-anal intercourse are sex workers, drug addicts and porn stars. Across the three country settings, participants noted a strong association between penile-anal intercourse and homosexuality, intimating that if a male partner requested anal sex from his female partner he must be a ‘closeted’ homosexual:

If a man turns and wants the anus it shows that he is homosexual … he also wants to do [have sex with] other men … a man should not fantasise having anal sex. … If you have anal, it means you are doing it with other men. (Victoria, Zimbabwean, age 24)

Illegality of penile-anal intercourseThe illegality of anal sex behaviour in Uganda and Zimbabwe was cited by some participants in explanation of why the behaviour is improper:

People get arrested and die in prison for homosexuality and having anal sex. It is not good. … There is an opening [vagina] for that [sex] … [anal sex] is not normal … it is not talked about openly …. It is embarrassing and it can get you arrested, meaning it is not good. (Kudzai, Zimbabwean, age 34)

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Relationship context and gender power dynamics of penile-anal intercourse

Penile-anal intercourse in casual relationshipsDespite the attitude that penile-anal intercourse is an embarrassing and shameful behaviour, 23% (20/88) of participants (South Africa n = 11/40, Uganda n = 6/22, Zimbabwe n = 3/26) disclosed their own past anal sex experiences in the interviews. When asked to comment on the relationship contexts in which penile-anal intercourse might be practised, women generally regarded penile-anal intercourse as inappropriate behaviour for married heterosexual couples:

[Anal sex] is practised between people who are just using each other. … They don’t love each other … I don’t believe that there is anyone who can do such a thing to someone whom he loves … this place [anus] is very bad. (Nomsa, South African, age 21)

Penile-anal intercourse for male partner satisfactionIllustrating gendered power and sexual scripting, most of the participants who disclosed having had penile-anal intercourse themselves said that despite not wanting to, they had done so in order to satisfy male partners. Women explained that if you love your partner, you must consent to whatever is necessary to ‘make him happy’:

you can’t refuse if you love him … you agree to everything. (Zodwa, South African, age 39)

Demonstrating the importance of male pleasure, some women explained that they derive pleasure themselves simply through pleasing their partner:

How can you not like the things that please your husband? (rejoice, Zimbabwean, age 22)

Penile-anal intercourse to ensure relationship securityParticipants suggested that women consent to have penile-anal intercourse as a means of ensuring relationship security, in the hope that agreeing to whatever kind of sex a male partner requests will give him no reason to leave and find another woman:

If you refuse anal sex, who do you want him to do it with? That’s what makes men to cheat … stepping out of marriage, so it’s better to do all the things he wants. (rejoice, Zimbabwean, age 22)

Despite sentiments that penile-anal intercourse is inappropriate behaviour for a married couple, maintaining relationship security and avoiding a partner’s wrath were seen as suf-ficient motivation for women to engage in penile-anal intercourse:

If [a man’s] wife refuses, he shuns her, he calls her stupid …. Because she does not want to lose her husband, she starts to use it [anus] and yet as married people, they should not be using it [anus] … [but] she does not want him to leave. (Lilian, Ugandan, age 26)

Lack of female partner agencyAcross all settings, participants described the lack of agency that women have in the sexual domain, where male partners control and initiate sexual interactions. Women insinuated male ownership of the female body and the prioritisation of male sexual pleasure, describ-ing the female body as being at the disposal for men to use as they wish. Thus, participants felt that they lacked the agency to refuse penile-anal intercourse when their male partners demanded it, even if they felt uncomfortable:

I do it [anal sex] for my partner, I don’t want to disappoint him … I’m not comfortable with anal sex … but I do it for [him] … [women] do it to make their partners happy … it’s the man who tells you to stand, turn around and do what he tells you to do. (Thembi, South African, age 27)

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With men as the initiators and aggressors in heterosexual sexual interactions, women explained that the threat of physical violence if they refuse, compels them to comply with a partner’s wishes:

A man comes up with that idea [of having anal sex] …. While you are having sex, maybe a man would tell you to turn and you just turn and do what he says … it’s not easy to refuse … women are afraid to speak for themselves … afraid that a man might beat them and accuse them of cheating if they refuse. (Nomvula, South African, age 26)

Forced penile-anal intercourseSix participants shared their experiences of having been forced to engage in penile-anal inter-course by their male partners. Some felt that the pain and physical trauma experienced as a result of un-anticipated receptive penile-anal intercourse enhanced the abusive nature of it:

you don’t want to and he [partner] ends up putting it [penis] in there [anus] by force … if you don’t want to, he will keep on touching you and end up putting it in there [anus] …. What are you going to say if a person is pushing by force, because that’s a fight right there …. The problem is males want it [sex] every time … it’s not like you decide that today I would get it …. He will then make you bend and put it in your anus … with me, I just don’t have the energy … if you said you don’t want to, he will start pushing you by force … I do it because I’m forced … not because we agreed. (Anele, South African, age 33)

‘Accidental’ penile-anal intercourseSix participants described having experienced situations in which a male partner has inserted his penis into her anus supposedly ‘by accident’. One sex worker described a situation in which she refused a client’s request for penile-anal intercourse, agreeing to have penile-vag-inal intercourse with him, only for the client to penetrate her anus claiming that it was ‘accidental’:

Most men are perverted, they want the anus, [laughs] they leave [the place] where you had agreed on [the vagina] and go to the anus …. I don’t allow anal sex … I push you away because I can’t do it [anal sex] … I pull you [penis] out …. you may get one [client] who asks you ‘can I go to the anus?’ and you say no, so if you refuse he may pretend to do it to look like it was by accident … that was his purpose …. you feel it when he is still on top because it [anus] is narrow and so if he starts to enter the anus you feel it … [then] I get him [his penis] and take him away [out of the anus]. (Agnes, Ugandan, age 25)

Motivations for penile-anal intercourse

Penile-anal intercourse as safer sexDespite its stigmatisation, participants described various scenarios in which a woman might engage in penile-anal intercourse. Some participants suggested that a woman might consent to penile-anal intercourse believing that it is ‘safer’ than penile-vaginal intercourse, and that by engaging in penile-anal intercourse she is reducing her risk of contracting STIs and HIV:

Some women think that anal sex is safer [than vaginal sex] … [they] think anal sex minimizes the risk of her contracting sexually transmitted diseases …. She then engages in anal sex, haaa, this issue is so complicated [laughing]. (Matipa, Zimbabwean, age 30)

Physical sensation of penile-anal intercourseOther reasons heterosexual men and women may engage in penile-anal intercourse have to do with the physical sensation of anal versus vaginal sex. Some women described the

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vagina being too loose; ‘the hole is too big in the front’. Thus penetrating the ‘narrow’, ‘tight’ anus, feels like ‘having sex with a virgin’, which is more pleasurable for the male partner. One participant explained that men are able to ejaculate more quickly through penile-anal intercourse than penile-vaginal intercourse, viewed as beneficial for both men and women. Participants explained that men enjoy ‘rough’ sex and the tightness of penile-anal intercourse that a parous vagina no longer offers:

The [anus] is narrow … in the anus, he has to struggle to enter … when I surrender to a man to have sex with me … because I have had many children, there is no need for him to struggle, because my vagina is wide, he enters easily without struggling. But men love narrow places … they want the entrances to be narrow so that they can force themselves inside. (Namakula, Ugandan, age 25)

The description of male preference for the tighter sensation of penile-anal intercourse was a commonly recurring theme; according to participants, loss of vaginal elasticity may result from either sex or childbirth:

The anus is tight since a baby’s head never came out of it …. They say that normal sex doesn’t feel good because it’s too loose there … the real thing [the vagina] has been through too much and has been made loose due to childbirth. The anus is not yet loose. (Jabu, South African, age 40)

Some women suggested that once a man has experienced the sensation of penile-anal intercourse he will no longer derive pleasure from penile-vaginal intercourse:

A man can’t have vaginal sex after anal sex … every time he comes he will be asking for anal sex … they enjoy it more than sex from the vagina … because the anus is narrow. (Agnes, Ugandan, age 25)

In illustration of the role of sexual arousal in sexual decision-making, two participants who disclosed having had penile-anal intercourse felt that although a woman is unable to refuse a partner’s advances, if she is ‘turned on’ [sexually aroused] she will no longer care what he makes her do. Of participants who spoke of their own experiences with penile-anal inter-course in the interviews, 4/20 said that they derived pleasure from penile-anal intercourse; of these, 3 said that they had begun to enjoy penile-anal intercourse after engaging in it repeatedly:

I am now used to it. It’s now in the blood … I enjoy it now … I just got comfortable with it and got into tune. (rejoice, Zimbabwean, age 22)

One participant said that after becoming accustomed to anal sex, she started to enjoy it more than penile-vaginal intercourse:

When you start doing it, it is painful, but once you get used to it, it feels good …. It is better than vaginal sex. (Fikile, South African, age 23)

Another participant admitted to enjoying penile-anal intercourse more than her male part-ner, describing occasions on which she has requested to engage in it, only for him to refuse:

It depends on whether or not a man likes to have anal sex. If he doesn’t like to, you can’t force him … you can’t bully him into doing it if he doesn’t want to. (Zanele, South African, age 25)

Penile-anal intercourse to maintain the vaginaFemale motivated reasons to engage in penile-anal intercourse included the maintenance of vaginal elasticity and tightness:

[Anal sex] is good for the front [vagina] because you don’t get loose [vaginal elasticity] too soon … when you do it at the back. (Nelisiwe, South African, age 23)

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Linked to the maintenance of vaginal elasticity, some participants suggested that women who are being unfaithful to a primary partner would have penile-anal intercourse to mask their infidelity, suggesting that their unfaithfulness would be detected if the vagina had been penetrated by another man. One South African participant explained that the primary partner would discover the amanzi endalo [natural water] remaining in the vagina after sex with the extra-marital partner; therefore, she explained, it is safer to tell your extra-marital partner to ‘go to the anus’.

Anal intercourse as relief when vaginal intercourse not possiblePenile-vaginal penetration during menstruation was regarded as inappropriate as men should not come into contact with menstrual blood, a ‘dirty’ substance. Therefore engag-ing in penile-anal intercourse as an alternative to penile-vaginal intercourse was described as a way for male partners to ‘relieve’ themselves or ‘please the flesh’ during menstruation:

If he [male partner] is aroused and wants to have a sex with a woman just to relieve himself, only to find that the woman is having her period, then he wants to insert it [his penis] there [anus]. (Phindile, South African, age 33)

Having anal sex while menstruating was described as a means of maintaining relationship security, ensuring that a male partner does not have reason to seek out other sexual partners when penile-vaginal intercourse is not acceptable:

[He] forces you [saying] ‘yes I want, I want’ [he wants sex]. … Even if you are in your menstruation period, he will say that ‘me I want’ [that he wants sex] …. Then you just have it [anal sex] … to keep my marriage. (Mirembe, Ugandan, age 39)

One participant described a situation in which her partner forced her to have anal sex after she’d refused to have vaginal sex because she was menstruating:

I was having my period and he [my partner] knew that … he asked me to take off my clothes … when I refused he said that he would have sex in my anus … I refused. Then he grabbed a hold of me and did it … It was very painful. I didn’t go to the toilet the following day. (Siphiwe, South African, age 31)

Participants repeatedly described the obligation that women have to satisfy a male partner’s sexual needs. Thus a woman suffering from vaginal complications, infections or sores has no option but to agree to have penile-anal intercourse, despite feeling uncomfortable with it:

[If ] the woman has some sores … on the vagina … the kind of sores that will make it difficult … to have vaginal sex …. But the man would be craving sex [laughing] … these will be wounds due to STDs … the husband tells the wife that he is so desperate for sex, what can he do [laughing]? … The only way out for the wife is to have anal sex with her husband! [laughing] … What else can the wife do? (Matipa, Zimbabwean, age 30)

Another motivation for engaging in penile-anal intercourse was in instances when the vagina is considered ‘too wet’. Vaginal fluid was generally viewed negatively by participants, referred to with words like ‘dirt’. Women who produce a lot of vaginal lubrication were described as having a ‘problem with wetness’, which would result in her male partner forcing her to have penile-anal intercourse:

People say there isn’t too much dirt [vaginal fluids] there [in the anus] … the men involved prefer not to have contact with a woman’s dirt … maybe the woman is producing a lot of vaginal fluids … they would not want to have contact with … those fluids … they are avoiding that. … This will lead them to have anal sex with a woman … it [anal sex] is just for pleasure and the man doesn’t find the messy fluids that will come out [vaginal fluids]. (Nhamo, Zimbabwean, age 40)

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Penile-anal intercourse for moneyOf the 22 Ugandan participants, 6 disclosed engaging in transactional sex; of these 6, 4 reported having had penile-anal intercourse with clients. For sex workers, financial gain was cited as a motivating factor for engaging in penile-anal intercourse:

Those that engage in anal sex are paid large amounts of money …. Someone is lured into anal sex to get a share of the large amounts of money … the men love it [anal sex] … [the women] get involved for the money. … If she knows that the pay is good, she will not mind …. Prostitutes are aware that they stand to gain financially from it [anal sex]. (Margaret, Ugandan, age 36)

According to the participants, sex workers get paid approximately five times more by clients for penile-anal intercourse than for penile-vaginal intercourse, providing a strong incentive to agree to penile-anal intercourse when clients request it.

DiscussionThis study, conducted with 88 women from South Africa, Uganda and Zimbabwe, demon-strates that penile-anal intercourse is a socially stigmatised sexual behaviour. The illegal status of penile-anal intercourse in Uganda and Zimbabwe influenced women’s percep-tions and negative attitudes towards penile-anal intercourse, as did cultural taboos around the behaviour, and religious beliefs. The social stigmatisation of penile-anal intercourse has roots in its association with homosexuality, religious sinfulness and the perception that the anus is dirty. Despite social norms framing heterosexual penile-anal intercourse as a socially unacceptable behaviour, 20 study participants reported having engaged in penile-anal intercourse and a wide range of motivations for practising the behaviour were revealed, suggesting that beneath the scripted ‘rejection’ of the practice was an acceptance or accommodation of heterosexual penile-anal intercourse. These findings point towards a disjuncture between the social stigmatisation of penile-anal intercourse and the motivations for practising the behaviour.

Whether they disclosed personal experiences or not, many participants described sit-uations in which penile-anal intercourse might be practised in heterosexual partnerships, and listed a variety of reasons for engaging in it. As described by participants, motivational cues for women to engage in consensual penile-anal intercourse are largely driven by ful-filling male sexual needs, in order to maintain relationship security and ensure male partner fidelity. Situational cues for penile-anal intercourse were linked to satisfying partner needs when vaginal sex was not possible, including during menstruation or in the presence of vaginal infections or excess vaginal fluid. One motivating factor that is most concerning is penile-anal intercourse being practised as a means of avoiding STI or HIV infection. There is insufficient understanding and limited documentation of penile-anal intercourse being practised as ‘safer sex’ by women in sub-Saharan Africa (Duby and Colvin 2014). Although most women did not report favouring or experiencing pleasure from penile-anal intercourse, three said that they learned to enjoy it, and one admitted preferring penile-anal intercourse to penile-vaginal intercourse.

Penile-anal penetration ‘by accident’ was another emergent theme, occurring in situations where a male partner inserts his penis into a woman’s anus instead of her vagina allegedly ‘by mistake’ (Exner et al. 2008). researchers in the UK who found similar narratives of both penile-anal and digital-anal penetration of women being described as occurring accidentally (‘it slipped’), suggest a limited ability to assess the extent to which ‘accidental slips’ were genuinely unintentional or in fact deliberate and non-consensual (Marston and Lewis 2014).

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Despite cultural diversity in traditions and customs regulating expressions of sexuality, there are universal commonalities, two of which are relevant to these findings: gendered power disparities and coercive sex (Maticka-Tyndale et al. 2005). As revealed by participants’ descriptions of the relationship contexts in which penile-anal intercourse occurs, and narra-tives of penile-anal intercourse being a male-initiated behaviour imposed in line with male prerogative, sexual scripts for penile-anal intercourse conform to conventional gendered power constructs, but suggest that women have even less control over penile-anal inter-course than penile-vaginal intercourse.

The power inequities inherent in most heterosexual sexual relationships are likely to contribute to the pressure placed on women to follow the submissive script and engage in penile-anal intercourse for the sake of their partner’s pleasure. Sexual scripts prioritising male over female pleasure and according primacy to the fulfilment of male sexual needs were evident in the accounts of participants who disclosed having had penile-anal inter-course, describing their experiences as painful. The prioritisation of male sexual satisfaction was evident in participants’ descriptions of situations in which a woman who is suffering from vaginal infections, or is menstruating, will agree to have penile-anal intercourse with her partner in order to satisfy his sexual needs and ensure that he needn’t seek satisfaction elsewhere. The description of penile-anal intercourse as an alternative to vaginal sex during menstruation was a common theme in participant narratives, and has been found in other sub-Saharan African research (Duby and Colvin 2014; Stadler, Delaney, and Mntambo 2007).

As witnessed in the accounts of participants, many women believe that male partners enjoy, and even prefer, penile-anal intercourse due to the tighter sensation of the anus as compared to the vagina. Similar findings regarding male preference for the tighter sensa-tion of penile-anal intercourse have emerged from research in Brazil (Halperin 1999), the UK (Marston and Lewis 2014) and East Africa (Duby and Colvin 2014). These findings are amongst the first to provide evidence of heterosexual men’s preference for the tightness of penile-anal intercourse from these three African countries, although this appears to be consistent with evidence from Africa suggesting a cultural preference for dry and tight vag-inal sex, coupled with the perception that friction during intercourse heightens male sexual satisfaction (Braunstein and Van de Wijgert 2005; Lees et al. 2014; Schwandt 2006).

A common theme emerging from the current study’s data, supported in the literature, is that of women engaging in sexual behaviours they dislike or are uncomfortable with for the sake of relationship stability and to avoid partner-perpetrated violence (O’Sullivan, Udell, and Patel 2006), which may place women at enhanced risk of HIV infection (Jewkes and Morrell 2010). Although reasons were listed for women having consensual penile-anal intercourse, the majority of participants who disclosed having had penile-anal intercourse describe the experience as painful and often associated with force, whether in the context of ‘stable’ relationships, casual partnerships or commercial sex. Non-consensual, or forced, heterosexual penile-anal intercourse is a key theme emerging from both the findings from the current study and other studies from South Africa (Stadler et al. 2007), the UK (Marston and Lewis 2014) and the USA (Maynard et al. 2009). These findings add to those from a previous study conducted in South Africa, suggesting that women engage in penile-anal intercourse to maintain relationship security and to avoid violence from their sexual partners (Varga 1997). receptive heterosexual penile-anal intercourse has been associated with abu-sive relationships and intimate partner violence, and women who report being in abusive relationships are also more likely to report repeated occurrence of penile-anal intercourse

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despite disliking it, and less likely to report condom use when engaging in the practice (Hess et al. 2013; roye, Tolman, and Snowden 2013; Varga 1997). The lack of agency that women have to control the timing of penile-anal intercourse, decreases their likelihood of success in using coitally-dependent HIV prevention products. However, the findings of this study suggest that a dual-compartment (vaginal-rectal) daily-use microbicide product could be an important development in HIV prevention.

LimitationsParticipants may not have been candid in disclosing their own opinions and personal expe-riences of penile-anal intercourse, as social desirability bias can influence responses, particu-larly for behaviours as socially stigmatised as penile-anal intercourse. These findings only reflect the views of heterosexual penile-anal intercourse from the perspective of women; for a more balanced view it would be important to interview men. In addition, the views expressed in these findings reflect those of the 88 women interviewed and may not be representative of women in their communities.

Scripting heterosexual penile-anal intercourse in AfricaPenile-anal intercourse occupies a taboo place in many cultures, and its practice tends to be shrouded in secrecy and shame. Social stigmatisation has hampered understanding of sexual scripts relating to this behaviour and communication around it (roye, Tolman, and Snowden 2013). Findings from this study suggest that in the case of heterosexual penile-anal intercourse, there is conflict between sexual scripts functioning at the individual (intraper-sonal) level, dyadic (interpersonal) level within the context of heterosexual relationships, and culture-level scripts. One critique of sexual script theory is that its social construction-ist underpinning leaves little room for the ‘individual scriptwriter’ who deviates from the prevailing cultural scenario, in this case represented by an African woman engaging in het-erosexual penile-anal intercourse (Giles 2006). Heterosexual women in Africa experience pressure from contradictory scripts operating at different levels: (1) culture-level ‘scripts’ categorising penile-anal intercourse as a sinful, shameful behaviour, (2) dyadic interper-sonal-level scripts informed by power inequities and gender roles stressing the importance of satisfying a male partner, (3) individual-level factors, such as sexual arousal and various motivating cues discussed above, with (4) situational variables such as the presence of vag-inal STIs or menstruation.

ConclusionThese findings provide unique insight into the sociocultural contexts within which hetero-sexual penile-anal intercourse occurs, the gendered power dynamics that are at play in the sexual decision-making around penile-anal intercourse, and the complex sexual scripting of heterosexual penile-anal intercourse among women in South Africa, Zimbabwe and Uganda. These findings demonstrate that sexual scripting for heterosexual penile-anal intercourse in sub-Saharan Africa is influenced by a complex array of factors; many of the individual, dyadic and social contexts of heterosexual penile-anal intercourse behaviour are distinct from those of penile-vaginal intercourse and need to be understood in their own right.

In order for HIV prevention interventions to be successful, situational factors, gender relations, sexual norms and relationship power dynamics need to be considered. Qualitative socio-cultural research helps unpack local meanings, interpretations, perceptions and

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attitudes that influence HIV risk behaviour and the adoption of prevention methods, ena-bling an understanding of the lived realities of sexualities and the contexts in which sexual behaviours are enacted (Maticka-Tyndale et al. 2005; McLellan-Lemal et al. 2013; Montgomery and Pool 2011).

Sexual scripting and decision making relating to penile-anal intercourse are complex; the HIV transmission risks associated with penile-anal intercourse are exacerbated by taboos that impede effective sexual communication and condom negotiation. Importantly, interventions designed to prevent HIV transmission through penile-vaginal intercourse may not work for penile-anal intercourse. By working towards an understanding of unique sexual scripts for heterosexual penile-anal intercourse in sub-Saharan Africa, sexual risk-taking and subsequent HIV transmission through penile-anal intercourse can be more effectively understood. With insight into the way in which individuals and communities perceive, construct and make behavioural choices regarding heterosexual penile-anal intercourse and HIV risk, we can design and implement more relevant, appropriate and effective HIV prevention interventions.

Our findings contribute to a greater understanding of the individual, relationship and social-contextual factors that influence perceptions and practice of heterosexual penile-anal intercourse in these sub-Saharan countries. These findings, which identify the specific sex-ual scripts and gendered power dynamics inherent in heterosexual penile-anal intercourse practice in sub-Saharan Africa, shed light on how heterosexual penile-anal intercourse and related practices might be contributing towards HIV transmission in the region. Evidence from this study can help to inform current HIV prevention priorities aimed at women in sub-Saharan Africa, as well as future prevention efforts that might address HIV transmission through this high-risk sexual behaviour.

AcknowledgementsWe would like to acknowledge the women who participated in this study. The full MTN-003D study team can be viewed at http://www.mtnstopshiv.org/studies/4493.

Disclosure statementNo potential conflict of interest was reported by the authors.

FundingThe study was designed and implemented by the Microbicide Trials Network (MTN). The MTN is funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the US National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health.

ORCIDZoe Duby   http://orcid.org/0000-0001-7615-8152

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